Caring, Not Curing At All Costs

While many Americans are unaware of it, every country in the world is now struggling, like the United States, to control health care costs. The most striking part of that struggle is that other nations all have that problem regardless of how they are organized. They are beset with three basic underlying drivers of modern health care: aging populations, great but often expensive medical technologies and high patient expectations. Most of the other countries do better than the United States in containing costs in great part because they maintain universal health care systems. But the United States does not have that advantage, and the net result is that it has the most costly system per capita of any other in the world and politically the most troubled.

The non-partisan Congressional Budget Office is charged with laying out plausible short-term and long-term cost scenarios for health care. These are dire and get worse with each future decade. What the C.B.O. cannot do, however, is make political predictions, but now that President Obama has been re-elected we can at least be confident that the implementation of the Affordable Care Act (A.C.A.) will continue.

During the campaign neither candidate wanted to directly confront the cost problem of American health care, particularly Medicare’s rising expense. The reason is not hard to uncover, that of the considerable resistance of the elderly—close to 80 percent in the polls—to any significant change in that program. For years the C.B.O. has been saying the same thing: Medicare costs can only be controlled by significantly raising taxes or cutting benefits or some combination of the two, but the electorate does not care for either option, alone or in combination.

The difficulty is that to have a significant impact tax increases aimed at supporting Medicare would have to be applied not just to rich Americans, but to the middle class as well. Increasing out-of-pocket costs should help bridge health care deficits, but under with the present program the average Medicare beneficiary already pays from $3,000-$5000 out-of-pocket each year; some can pay as much as $10,000. Keeping in mind the financial security of the elderly, intertwined with the Medicare coverage, it is not clear how much higher can out-of-pocket charges can be raised.

While the Social Security program is in fairly good shape for the foreseeable future, it will not cover by far the income needs of most beneficiaries (and was never intended to do so); And 75 percent of those over 65 in 2010 were retiring with only $30,000 in personal retirement funds. Some of that small savings must of course pay for the Medicare out-of-pocket costs.

Controlling Costs

In short, aside from the most affluent, there are certain to be great financial burdens on the elderly in the future, well beyond those they already endure with the present Medicare and Social Security programs. How are we even to imagine benefit cuts in that context? Nothing but pain is in store for us and even more for those nearing 65 but not yet there. The A.C.A. will cut costs to a considerable extent over the next decade, particularly because its Independent Payment Advisory Board will be able to enforce automatic cuts in the Medicare program if expenses are not controlled. But beyond that kind of brute financial force most of the A.C.A. cost cutting provisions are speculative in their actual impact and even more so over a 20-30 year period. Wisconsin Congressman (and recent vice presidential candidate) Paul Ryan’s proposal remains the most plausible to come from the Republican Party. It gradually shifts more and more of the economic burden on the elderly themselves.

Far more difficult to comprehend is the nature of the cost problem itself, and I want to distinguish between a managerial and a philosophical belief. The managerial belief, by far the most commonly embraced, is that better organization and management can solve it. Our health care system is, among other things, inefficient and wasteful, makes poor use of scientific evidence in patient treatment, offers the wrong kind of financial incentives for physicians and hospitals and is altogether too expensive. But all that can be reformed—or so the argument goes.

But at a deeper level, the problem is also that of the philosophical model and vision of medicine that the health care system is based on—and it is at bottom the reason every country, not just the United States, is struggling. It is the progress- and innovation-driven model. It has made death the ultimate enemy and is dedicated to a utopian vision of medical progress that neither recognizes nor accepts any inherent limits. That is not a vision that can be coped with by better management. It is not our health care failures that are the ultimate problem. The trouble lies with it very success.

To make that view comprehensible, it may be useful to look at some basic data, to examine the leading causes of high costs, and at the place of chronic illness and death in health care. I will focus on Medicare. In 2010 it covered 40 million people over 65, with a projection of 88 million by 2050. The fastest growing U.S. age group are those over 85. Why is there a problem? The three basic cost drivers all come into play in the high cost of caring for the chronically ill, mainly the elderly suffering from hypertension, heart disease, diabetes, cancer and Alzheimer’s disease.

The top 1 percent of such patients account for somewhat more than 20 percent of spending ($275 billion in 2009), and the top 5 percent almost half of the spending ($623 billion). The bottom 50 percent cost only $236 per capita; the top 5 percent $41,000; and the top 1 percent $90,000 per capita. It is the success of keeping sick people alive much longer than in the past that is at once a great medical triumph and the source of the health care system’s greatest economic stress. An important part of that problem is costly end-of life-care, not just the few days or weeks while patients are obviously dying but the often longer preceding time when it is not certain whether a person is dying or not, when they are vigorously treated with the hope that they are not at death's door.

Tough Prognosis

Here are what I think of as hard medical facts, but ones that hardly anyone wants to accept because they call into question some fundamental values of the modern medical enterprise. Three of them stand out:

Medical research, much cherished, sometimes helps to lower costs but in the aggregate over the years it has increased them. It has done so not by curing the major chronic diseases, which it has failed to do, but by its capacity to keep people with them expensively alive for a longer period of time.

Cures and prevention can have wonderful benefits for individuals but the cure of one disease simply means they will die of another. It is what I call the longitudinal costs that matter for society, the total accumulated costs of each illness incurred over a lifetime. A person’s life can be saved from heart disease at 65, from cancer at 75, a repairable stroke at 80 and they will survive to get Alzheimer’s at 85. There is a bill for each successive victory over death. We can all think of friends or relatives who have spent their last years in and out of I.C.U.s.

Technological innovations usually yield marginal benefits only but often at a high cost. The emergence in recent years of exceedingly expensive cancer drugs—from $50,000 to a whopping $320,000—that yield only a few additional weeks of survival stand out as startling examples of expensive innovations, not to mention the many less expensive but costly innovations that, taken as a whole, make I.C.U. care so costly. The latter can be called the high altar of innovation, where belief in progress is most pronounced and most costly.

Just as false hope feeds a good share of the costs of chronic illness, so also it feeds a belief in organizational miracles. In the end it is not just the health care system that needs reform, but the way we think about medicine itself. An open-ended belief in progress and innovation led us into the chronic illness morass, and no way out is at present visible. The great biologist Rene Dubos many years ago wrote a book with the prophetic title The Mirage of Health. Illness, decline and death are an intrinsic part of our human nature, never to be overcome, he argued. After years of rising, average life expectancy shows signs of leveling off. Nature may well be reminding us now to take Dubos’s analysis more seriously than we have.

A reform of medicine will require a number of steps. Above all it will necessitate a rethinking of medical progress, one that works with finite, affordable goals. The most important goal would be to accept death in old age, to realize that a boundless fight against it may satisfy many of us personally but be financially harmful to us as a community; and in any case extended chronic illness in our last years under the present regime is too often more a burden then a blessing.

The place I would draw the line is 80, not a hard and fast line, but one that should lead us to a shift in perspective. Once one reaches that age, most people have lived full lives and have had the opportunity to enjoy most if not necessarily all of life’s benefits. I am now 82 and, while I hope my family and friends will be sorry to lose me when I die, I cannot imagine that I will be an irreparable loss to our common good. Others will take my place. I flatly oppose euthanasia and physician-assisted suicide, but I do not consider it an inherent evil that we all get old and die, nor do I believe that Christianity does. It is not an insult to our human dignity that our lives are finite. I do not believe in a level playing field for each age group. Children should have the highest priority, the working adult cohort responsible for running the society and raising the children should come next. The elderly, like myself, should come last. I have six children and five grandchildren, and I worry about a health care system for the elderly that shuts its eyes to the burden on younger people.

Many may find this way of thinking altogether unacceptable. They believe that it is simply immoral to use cost as a sometimes necessary standard for setting health care priorities or that such an accounting reflects ageism at its worst. I believe that society has an obligation to help young people to become old people, but it cannot exhaust public resources to help old people become older indefinitely, nor can it be indifferent to the burden on younger people whose payroll taxes pay for health care for the elderly.

I have an organizational plan to go with the reformed medicine I have in mind. Picture a pyramid. At the bottom would be public health, the next level would be primary and emergency medical care. Above that would be routine hospital care. The next level would be advanced hospital care, including ICU care for those with a good prognosis. At the very top would be the expensive high-technology procedures, and particularly their use with those over 80 with a borderline or poor prognosis for a much longer life thereafter. The aim of the health care system would thus be to make the lower levels affordable and accessible to all, but increasingly curtailed at the highest levels, pushing everything down the pyramid as far as possible.

The elderly would not, under this plan, be neglected. They would require and still receive good primary care, economic sustenance, available and subsidized support from family members or others and the building of aging and assisted living communities integrated into the life of younger people. Cure has been in the medical saddle too long and has lost its way. It should now be better balanced with care. We need, that is, not just better management of health care, but a fundamental change in the goals of medicine and the way we think about aging.

Daniel Callahan is President Emeritus of The Hastings Center and the author of two books to be published this fall: a memoir entitled "In Search of the Good: A Life in Bioethics" (MIT Press) and a collection of his essays "The Roots of Bioethics: Health, Progress, Technology, Death" (Oxford University Press).

You’re old enough. You’ve lived long enough. Die! At least Dr. Callahan has been consistent since there was an article about him, “Examining the Limits of Life,” in Time Magazine, Science and Technology, November 2, 1987 (available free online), when he was a lad of 57. When I first read it I was wondering how he would feel when he was a senior.

Next month I will reach the venerable age of 76, a little short of the reasonable limit that Dr. Callahan proposes. I am in virtually perfect health, working out at the gym with heavy bodybuilding five or six days a week, two hours or more a day, and I run. (My prior physical conditioning was an important element in saving my life from myxofibrosarcoma in 2004 and prostate cancer in 2005, along with my orneriness.) I am productive, working as an English teacher and a translator (Portuguese and English). I have a loving family with a two-year-old granddaughter, my favorite English student, Nina, and good friends. I am an expatriate patriot who lives in one of the world’s most beautiful cities, Rio de Janeiro. I was here first, and, as long as I am a healthy jock with a sound mind, I will not willingly cede my space to newcomers.

Unfortunately, I can not make use of Stateside Medicare in Brazil, so I have to pay a considerable sum monthly for health insurance for my wife, Denise, and me, but that is not the issue here.

Dr. Callahan wrote, “. . . nor can it [society] be indifferent to the burden on younger people whose payroll taxes pay for health care for the elderly.” Lest anyone forget, it was us now elderly who paid payroll taxes for the health care of those who were then elderly when we were youngsters, and we are only collecting our just due now. After all, this is the idea of Social Security and health insurance in the first place. If there is not enough money in the kitty, then the government’s – our – priorities have to be rearranged. Let us spend our money on peace instead of war, even if it is less profitable.

Let me make a final point clear. I favor quality and not quantity of life. There is indeed a natural limit, but it need not be a predetermined range of ages. It is all very individual.

I work in health care, and I support universal coverage for health care in the U.S. The ACA is a step toward that.

An important factor to consider is that the majority of money spent for health care in an individual's lifetime is spent in the last year or two. We spend a lot of money delaying death by a few months, and it is money that would be better spent providing coverage for everyone. Another interesting thing is that doctors, when faced with a terminal illness, opt for much less treatment than most people. Informed consumers might actually want less treatment than they now get.

Since I work in the health care industry, I probably fall into Callahan's "managerial" category, although I agree with many of his points. I tend to think, however, that there are other approaches to reducing Medicare cost growth that are more politically and operationally feasible (and probably more effective) than simply a ban on high tech/high cost procedures for those over 80. Most studies I've seen suggest that the potential savings in this area are much lower than people think.

First of all, we should accelerate Medicare's move away from fee-for-service payment and toward approaches that reward health care systems for investing in primary and secondary prevention. There are a number of demonstration projects in the ACA along these lines. We need to identify which approaches work best and move quickly to implement.

Secondly, even with the existing system, there are things we could do better. We could allow Medicare to act like a real insurance company, negotiating better deals with hospitals and physicians in exchange for preferentially routing patients to them. In particular, Medicare should be allowed to use its purchasing power to negotiate better prices for pharmaceuticals. Medicare should also be allowed to coordinate with Medicaid and private insurers in establishing "all-payer" rate setting (Maryland has such a system, and their cost growth has been below average).

Thirdly, we should not simply throw up our hands and despair of being able to change patient preferences. There are many opportunities to use "shared decision making" tools to help patients and their caregivers understand the costs and benefits of certain treatments. While hospice continues to be underutilized, its use is growing. Requiring patients to have living wills and/or durable powers of attorney on file before proceding with surgery is also a good practice. Investing time and energy in these efforts does not make a lot of financial sense for hospitals reimbursed on a fee-for-service basis (or physicians struggling to get everything done in a 15 minute office visit), but they would make sense if we re-ordered the incentives by changing the reimbursement system.

Finally, I would note that Medicare-on a per capita basis-is currently doing a better job keeping costs under control than the private sector. It is the sheer number of new enrollees that are driving the long-term cost projections.

I'm 80 now, in fair but declining health, and I think that the author is on the right track. He states the prolem correctly when he writes of the philosophical vision of health care that "neither recognizs nor accepts any inherent limits," whereas in actual fact such a model is financially unsustainable. Resources are limited. We can only pay so much. But when that realization strikes home, what an uproar there will be. The naysayers will scream "death panels." The super rich will be able to afford treatments that the vast majority cannot. Today there is fierce argument over abortion. I think the one that will come someday over the author's thesis will be even more animated. I hope, however, that the citizens of our nation will eventually come to work toward a solution where we all can have decent care as we move on toward the unavoidable end of our earthly lives. I believe that is what Dan is asking too. He has given much thought to this in his own fruitful life. His proposal deserves much thought and much discussion on a wide basis, and I hope it gets it.

Wow. What an essay, and what rich responses. The best rebuttal I think one could make of Mr. Callahan's argument is Mr. Callahan as revealed in his essay. 80 plus or not, his brain, wisdom, spirit, and good will are evidently going full bore. I would hate to see him check out in the near future. For our sake. We can't afford to lose too many Callahans prematurely. His eternal reward, at which Diane (#1) references, can wait for now. Eternity can't be rushed anyway.

Ed (#2), while I always admire your Christ-like spirit even when you botch its application in the real world, here I'm not sure whether your comment is saintly or nuts (yes, I know the two are not mutually exclusive). You want the health care that a villager in Bangladesh would receive? I thought we were all working for a better world in which the villagers of Bangladesh don't have to experience the health care of the villagers of Banladesh.

But do we have to have such a procrustean take on things? Who is to say how much life or value an 80 year old has left in the tank? Michelangelo's great sculpture of the Deposition in Milan is one of his greatest works, which he hacked out in his 80's. Why not develop a system in which the individual is allowed to have input? Currently in England a bureaucracy determines how much a year of "quality" life, which quality they, not you, define, is worth, about $50K, and apply this value to how many years of such life an older person can expect to receive from a certain procedure. If said person meets the budget, thumbs up; if not, it's curtains for him. And we are going to have to do something similar, as Mr Callahan implies. Yet why not allow the individual input? Who on this side of the ledger has a better perspective on his life than he does?

For example, previously I had a $5 million limit on what my insurance would pay to sustain my earthly form. I thought that was enough for me to pay for and for the society to sustain. Now I understand that top will come off. Perhaps we could have the option of a basic insurance that would limit the kind of procedures Dan Callahan suggests above a certain age, but have the option to pay for a supplementm which could vary according to controllabe risks such as smoking, age, weight, should we desire more extensive care. The idea would be to involve the individual in his health care choices.

How the person values his own years, including his later years, should be at least a factor in the level of care he receives.

I am supportive of ACA and appreciate the President and his supporters in facing this long-time issue squarely. Not perfectly, by any means, but at least making progress. I am concerned that "business as usual" will prevail eventually, i.e., that the private marketplace with their economic power will continue to trump broader needs or concerns of the community.

I resonate with Mr. Callahan's comment that medical research is less than effective in keeping costs down. Look at the enormous sums invested not so much to improve quality of care as to develop "kitchy" products - viz. the latest drugs to "improve" quality of life but which mainly serve to enrich pharmaceutical companies and their investors. Also, I question the validity of multiple public solicitations that tout research as their goal. The public has been numbed to this ongoing barrage, accepting the perception that "research" is essentially good when it may not always be productive, efficient or effective.

When I was a medical student, many experienced, caring mentors exercized the principles articulated by Mr. Callahan. Surgery on a patient over 80 was generally considered overly aggressive care. Fear of a malpractice suit has been a major cause in reversing the practice of the the docs back in the day.

Since "Care" is the lead word of the articles's headline, I would note that the main health care issue in Americal is still the 50 million uninsured, not the 40 million Medicare population. Hopefullly, ACA will reduce the uninsured to 23 million. Then Mr. Callahan's article on the affordability issue will take center stage, since ACA took the politically expeidient step of achieving limited gains by throwing money at the same old dysfunctional American health care "system." Medicare for all could provide a rationally-run, compassionate, universal and cost-effective health care system for America.

The principles and standards in the article ring true. It is especially important that they be championed by us seniors. Perhaps AARP could endorse them.

Mr. Callahan believes that the base of the health-care problem is "the progress and innovation-driven model." The truth is that our highly regulated health care market is our problem. Do you know what drives the "the progress and innovation-driven model? Cost controls and third party payers.

When we set up a limit on what we'll pay for a procedure, device, or drug, that reimbursment never goes up - only down. How do people respond? They invent something new and reset the price higher. In a normal market, people could choose the older, cheaper, and more settled solution but when they are not involved in the purchase process, that doesn't happen. We think that a universal system would fix this. Today we have an example of a very large universal payer system in the US - the Defense department. How's cost control doing over there? Even if you take away the uneccesary wars, it's a highly inefficient system. A universal healthcare system would be no better as demostrated by other countries.

We need to separate our intentions from the implementation. All of the good intentions for healthcare have actually brought us the system we have today: high cost, falling quality, and soon a shortage in supply as health care professionals opt out of the system. For the open-minded, another path:

If the government agencies that run these programs were more trustworthy, I'd vote for universal healthcare in a heartbeat; simply stated they are not. Medicine has been big business for many decades... what a shame.

I was a practicing surgeon at a major NYC medical center for forty years, follwed by a short stint as a volunteer in Africa. These issues of life/death and reasonable terminal care are not as hard as they are made out to be. The most memorable issue in my career did not involve the elderly; in fact they were about a toddler dying and whose parents were struggling with the inevitable. My pediatric (and geriatric) oncologist associates have to deal with this every day 24/7/365.

How would you deal with cases like Rep Kathy Giffords, whose exceptional care cost a fortune, and head wounds to a ghetto kid who deserves the exact same care ?

Costly as the health care system is (18-20% GNP), if I had a say, I'd pay it and cut back on useless, expensive and immoral wars... not likely, the industrial miliary complex wins every time.

Both Diane and Callahan have nailed it about end of life costs and how to vastly modify them with a truly Christian message. DC says ." The elderly, like myself, should come last. I have six children and five grandchildren' "At 80 I am in the same six children boat as Callahan {more grandchildren though...Ha]My short instructions to my provider are " don't do any procedures that they can't do in a village in Bangladesh" palliative care.. is the ticket.This Catholic position ought to be promulgated more if we still preach/believe that this life is not the end. With all the gray hairs in the parishes now this message is more relevant than the too usual, 'black helicopters are coming to round up Catholics' Let's put our bodies where our beliefs ought to be.

My father practiced internal medicine until he was almost 70 years old. My husband practices emergency medicine now. The premise you write about is a frequent discussion at our house, especially since my father is almost 80. He too has marked that age as "the beginning of the end" and though we will do all we can to preserve his quality of life, we agree we would not go to heroic means. My husband tells me that this kind of thinking is not typical of most elderly, sick patients when asked it they want to be revivied or put on live support. No one wants to die, but, we must discuss persistantly about the economic consequences of our decisions. We must consider our children's and grandchildren's future. I applaud your writing and hope that you will be able to stimulate and continue this discussion in a larger forum so we all of America begins to consider the greater good and not just their fear of death or unwarranted faith in the cures of medicine. I think our pervasive secular ,materialistic society helps to breed this vicous circle. If more of us truly knew God and lived our lives with him, we may not be so afraid to meet him in the next life. It is hard to let go when you do not know where you are going. Good luck with promoting your message!